Primary Tunnel Dilatation in Tibia, An Unrecognised Complication of ACL Reconstruction

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1 Abstract # Primary Tunnel Dilatation in Tibia, An Unrecognised Complication of ACL Reconstruction Prakash Ayyadurai, Suresh Perumal, Parthiban Jeganathan, Karthik Parachur, Arumugam Sivaraman Sri Ramachandra Institute of Higher Education & Research Centre for Sports Science, Chennai, India SRIHER (DU) Center for Sports Science

2 Financial Disclosure Name: Dr.Prakash Ayyadurai Qualification: MS(Ortho) No financial conflicts to disclose No company affiliations Name of employing Institute: Sri Ramachandra Institute of Higher Education & Research, Centre for Sports Science, Chennai, India SRIHER (DU) Center for Sports Science

3 AIM To study primary tunnel dilatation in tibia as an intra-operative complication during anterior cruciate ligament reconstruction. SRIHER (DU) Center for Sports Science

4 Background Several methods of ACL reconstruction exist, the two most common are ACL reconstruction with BTB graft and reconstruction using a hamstring tendon (HT) graf t1. Among the related complications, tunnel enlargement has been reported as a long term complication in recent years regardless of the technique used 2-5. Primary tunnel dilatation can be described as widening of bone tunnel intraoperatively while fixing the graft with interference screws. This complication is more common in tibia and rarely happens in femur owing to the compactness of bone in femur. It is not well understood nor discussed in arthroscopy literature. We describe primary tunnel dilatation as an unnoticed intra-operative complication during ACL reconstruction

5 Materials & Methods Study design: Prospective study in single centre Study period: Total patients: 1543 Patients were grouped according to chronicity Group 1: Acute (3weeks) Group 2: Sub-acute (3-6weeks) Group 3: Chronic (>6weeks) All patients undergoing primary ACL reconstruction irrespective of the graft choice were studied for the occurrence of primary tunnel dilatation Occurrence was noted during fixation of ACL graft in the femoral & tibial tunnel and recorded.

6 Surgical technique for all cases General anaesthesia. Diagnostic arthroscopy. ACL tear confirmed. Group 1: BTB graft 1. BTB graft harvested through a mobile window technique. 2. Transtibial drilling technique for femoral bone tunnel 3. Graft fixation with metal or bioabsorbable fixation Group 2: Hamstring graft 1. Hamstring graft harvested through a vertical incision over per anserinus. 2. Transportal drilling technique for femoral bone tunnel 3. Graft fixation with femoral endobutton & metal or bio-absorbable interference fixation in tibia Tibial tunnel was made using impaction reamer. Primary tunnel dilatation was observed while fixation of tibial interference screw and tackled with a larger diameter screw or secondary fixation with suture button or post.

7 Inclusion criteria Exclusion criteria Age of 18 to 55 years Age of <18 or >55 years Isolated ACL reconstruction Unilateral ACL reconstruction No signs of grade II osteoarthritis on radiographs. Concomitant injury (including collateral, posterior cruciate ligament, meniscal & chondral injury) Previous knee surgery SRIHER (DU) Center for Sports Science

8 Results n=1543 Male 85.98% Female:14.01% Age: years: 56.19% years: 28.48% 40 years & above: 15.31% Chronicity Acute:109 cases (7.1%) Sub-acute:737 cases (48.04%) Chronic: 688 cases (44.86%) Primary tunnel dilatation: 129 patients (8.37%) Further analysis: Primary tunnel dilatation: Chronic (73 cases %) Sub-acute (37 cases %) Acute (19 cases %)

9 Discussion Many studies have observed graft tunnel dilatation following ACL reconstruction as a mid-term, long term complication of ACL reconstruction 2-5. The tunnel enlargement observed has been greater with use of STG graft than BTB graft 3. However the primary tunnel dilatation has never been described in literature to our knowledge and we feel its a important intra-operative complication to be noted. Long term followup and its correlation to secondary tunnel dilatation needs to be studied in detail.

10 Conclusion Primary tunnel dilatation is a unrecognised complication in ACL reconstruction. Bone quality should be given due importance while performing such surgeries. ACL reconstruction performed in sub-acute stages can avoid this complication.

11 References 1. Silvers HJ, Mandelbaum BR. Prevention of anterior cruciate ligament injury in the female athlete. Br J Sports Med 2007; 41(Suppl 1): i52 i Hersekli MA, Akpinar S, Ozalay M et al (2004) Tunnel enlargement after arthroscopic anterior cruciate ligament reconstruction: comparison of bone-patellar tendon-bone and hamstring autografts. Adv Ther 21(2): Abdalla RJ, Monteiro DA, Dias L, et al. Comparison between the results achived in anterior cruciate ligament reconstruction with two kinds of autologous grafts: patellar tendon versus semitendinous and gracilis. Rev Bras Ortop 2009; 44: Eriksson K, Anderberg P, Hamberg P, et al. A comparison of quadruple semitendinosus and patellar tendon grafts in reconstruction of the anterior cruciate ligament. J Bone Joint Surg 2001; 83-B: Webster KE, Feller JA, Hartnett N, et al. Comparison of patellar tendon and hamstring tendon anterior cruciate ligament reconstruction: a 15-year follow-up of a randomized controlled trial. Am J Sports Med 2016; 44: SRIHER (DU) Center for Sports Science